ADOLESCENT IMMUNIZATIONS Katalin Koranyi, MD Professor of Pediatrics Nationwide Children’s Hospital Department of Pediatrics College of Medicine The Ohio State University

What is HPV? Skin (e.g., warts on the hands and feet) Human papillomavirus (HPV) is the name of a group of viruses that infect: Skin (e.g., warts on the hands and feet) Mucous membranes (e.g., mouth, vagina, cervix) There are more than 100 different types of HPV.

About 30 types of HPV affect the genital area “High-risk” types: Can cause abnormalities of the cervix (the lower portion of the uterus or womb) that sometimes turn into cancer. “Low-risk” types: Can cause genital warts and abnormal but noncancerous changes in the cervix. All types of genital HPV can cause abnormal Pap tests.

How does a person get HPV? Anyone (man or woman) who has any kind of sexual activity involving genital contact with an infected person can get HPV Intercourse is not necessary Most people do not know they have HPV Because most infections do not cause symptoms

HPV Infections People can pass the virus on without even knowing it Most people get HPV within their first 2 to 3 years of becoming sexually active By age 50, at least 80% of women will have acquired genital HPV infection American Cancer Society Cancer Reference Information – Frequently Asked Questions About Human Papilloma Virus (HPV) Vaccines;pg.20 American Cancer Society. Frequently asked questions about human papilloma virus vaccines. American Cancer Society Website. http://www.cancer.org/docroot/cr1/content/crl2_6x_FAQ_HPV_vaccines.asp. Accessed July 14, 2008

Most new cases of HPV occur in adolescents and young adults Women are at risk of acquiring an HPV infection from as few as 1 sex partner Risky sexual behavior is not necessary New cases of genital HPV in a year in the US Approximately 6 million 1. Winer RL et al. J Infect Dis. 2008;197(2):279-282.

What are the consequences of HPV? 1.4 million new cases of mildly abnormal cells 3,670 estimated deaths 1 million new cases of genital warts 330,000 new cases of highly abnormal cells 11,150 new cases of cervical cancer

Genital HPV and how it affects the female anatomy The Female Reproductive Tract The uterus is a hollow, muscular, pear-shaped organ located in the female pelvis between the bladder and the rectum. The main function of the uterus is to sustain a developing fetus during pregnancy. The cervix, often called the neck of the uterus, is the lower portion of the uterus that opens into the vagina. The cervix is composed of squamous epithelium (which covers the exocervix or the part of the cervix next to the vagina), and columnar epithelium (which lines the endocervical canal, the part closest to the body of the uterus). The transformation zone is the area of the cervix where the process of gradual replacement of the immature columnar cells with the new mature metaplastic squamous epithelium occurs. Over the past few decades, the prevalence of adenocarcinomas appears to have increased. This could be due to an increase in the overall prevalence of Human Papillomavirus (including Types 16 and 18, which account for most adenocarcinomas) as well as the fact that adenocarcinomas are not as easily detected during cervical cancer screening as squamous cell carcinomas. This is because unlike squamous cell carcinomas, which usually originate in the transformation zone, adenocarcinomas often arise in the endocervical canal, which is less accessible to Pap testing.

How do Pap tests help prevent cervical cancer? Pap test detects abnormal cervical cells Treating abnormal cervical cells early can almost always prevent cervical cancer from developing

Cervical cancer About half of all women diagnosed with cervical cancer are between 35 and 55 years old Many of these women may not realize is that they were most likely exposed to one of the “high-risk” types of HPV during their teens and 20s

Genital warts Genital warts are flesh-colored growths that are caused by certain “low-risk” types of HPV The types of HPV that cause genital warts are different from the “high-risk” types that can cause cervical cancer After sexual contact with an infected person, the warts may appear within weeks or months

What do genital warts look like? Genital warts don’t always look the same Some warts grow inside a woman’s vagina, or on the cervix, making them hard to see

Summary What is HPV? How can a person get HPV? Human papillomavirus (HPV) is the name of a group of viruses that infect the skin and mucous membranes. There are more than 100 different types of HPV, which include “high-risk” and “low-risk” types. How can a person get HPV? Anyone who has any kind of sexual activity involving genital contact with an infected person can get HPV. Intercourse isn’t necessary, and transmission can take place by oral-to-genital, hand-to-genital and genital-to-genital contact. HPV affects both women and men.

GARDASIL: An HPV Vaccine HPV 6/11/16/18 L1 virus-like particle (VLP) vaccine The vaccine is effective Prevents cervical, vulvar and vaginal cancers caused by HPV 16 and 18 70% of cervical cancer Prevents genital warts caused by HPV 6 and 11 90% of genital warts Adverse reactions to the vaccine Pain and swelling at the injection site Fainting

CDC, AAP, AAFP Recommendations CDC/p. 16/col 2/¶2. Routine vaccination with 3 doses of HPV vaccine for females 11–12 years of age Can be started as young as 9 years of age Catch-up vaccination for females 13–26 years of age not previously vaccinated or who have not completed the full vaccine series Ideally, vaccine should be administered before potential exposure to HPV CDC/p. 16/col 2/¶3. CDC/p. 17/col 1/¶2. CDC/p. 17/col 1/¶3. CDC/p. 17/col 1/¶6. Package insert/ p.8/lines 249, 252 Key Point ACIP recommendations for the quadrivalent HPV vaccine indicate routine vaccination for females 11 to 12 years of age with catch-up vaccination in females 13 to 26 years of age. Background Recommendations for use of quadrivalent HPV vaccine1: Routine vaccination with 3 doses of quadrivalent HPV vaccine is recommended for females 11 to 12 years of age. The vaccination series can be started in females as young as 9 years of age. Catch-up vaccination is recommended for females 13 to 26 years of age who have not been vaccinated previously or who have not completed the full vaccine series. Ideally, vaccine should be administered before potential exposure to HPV through sexual contact. However, females who might have been exposed to HPV should be vaccinated. Quadrivalent HPV vaccine can be administered at the same visit that other age- appropriate vaccines are provided, such as Tdap and quadrivalent meningococcal conjugate (MCV4). – NOTE: Although ACIP states that the quadrivalent HPV vaccine can be administered with these other vaccines, per the prescribing information, co-administration of GARDASIL® [Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant Vaccine] with these vaccines has not been studied. Reference: 1. Centers for Disease Control and Prevention. Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2007;56(RR-2):1–24. 1/CDC/p. 16/col 2/¶2. 1/CDC/p. 16/col 2/¶3. 1/CDC/p. 17/col 1/¶6. Package insert/ p.8/lines 249, 252

Summary: GARDASIL GARDASIL is a vaccine indicated in girls and women 9 to 26 years of age for the prevention of cervical, vulvar, and vaginal cancers; precancerous; and genital warts caused by HPV Types 6, 11, 16, and 18 GARDASIL is contraindicated in individuals with severe allergic reactions to yeast Gardasil does not substitute for routine cervical cancer screening

Pertussis in an adolescent 10 fold rise in incidence in recent years

Adolescent Pertussis on the Rise Incidence 2004 23.86 10-fold Increase in 10- to 19-year olds Incidence 1994 2.33 Adult Incidence Slide 37. Adolescent Pertussis on the Rise The highest incidence of pertussis is among infants <6 months old (not shown on this graphic). Although infant pertussis is particularly disturbing, the incidence of pertussis disease had begun to shift and increase among the adolescent population in the 1990s. Between 1990 to 1993 and 1994 to 1996, the reported incidence of pertussis increased among children and older individuals; however, the largest increase (106%) occurred among adolescents aged 10 to 19 years. Between 1994 and 2004, a further 10-fold increase was seen in reported incidence in this age group (solid blue line). Centers for Disease Control and Prevention. Pertussis Surveillance Report – 8/12/05. Centers for Disease Control and Prevention. Summary of notifiable diseases, United States, 1994. MMWR. 1995;43:1. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Hamborsky J, Wolfe S, eds. 9th ed. Washington, DC: Public Health Foundation, 2006;79-95. Murphy TV. Epidemiology of pertussis in the United States in the context of a childhood DTaP vaccination program. Presented at: ACIP, February 11, 2005. 1983 1986 1989 1992 1995 1998 2001 2004

Licensed Tdap Vaccines for adolescents Composition PT + FHA + + PRN + + FIM + Boostrix Adacel *PT = Pertussis toxin; FHA= Filamentous hemagglutinin; PRN = Pertactin; FIM = fimbrial agglutinogens

Meningococcal infections

Recommendations for Meningococcal conjugate vaccine All children aged 11-18 yrs Adolescents entering high school (if not previously vaccinated) College freshmen living in dormitories Persons ≥ 11 yrs at high risk for meningococcal infection Children aged 2-10 years if at high risk for meningococcal infection